Transcript ACO Impact ACOs use specific clinical data

Steven E. Wegner, MD JD
Chair, NCMS Accountable Care Task Force
Paul Cunningham, MD
NCMS Accountable Care Task Force
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Steve Wegner
[email protected]
(919)380-9962
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What is this?
…and
why should I care?
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- Peter Orszag, N Engl J Med, 2007
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- Baicker et al. Health Affairs web exclusives, October 7, 2004
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“ Even if federal health overhaul is rejected by
the Supreme Court or revamped by Congress,
the market must continue to change. The
system that brought us to this place is
unsustainable. Employers who foot the bill for
workers’ health coverage are demanding that
BlueCross identify the providers with the
highest quality outcomes and lowest costs.”
- Brad Wilson, President of BlueCross BlueShield of North Carolina
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“ACOs consist of providers who
are jointly held accountable for
achieving measured quality
improvements and reductions in
the rate of spending growth.”
- Mark McClellan, Director of the Engleberg Center for Health Care Reform at the Brookings Institution
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ACOs are not gate keeper; ACOs do not require
patient enrollment.
ACOs do not require changes to benefit structures.
Can provide or manage continuum of care as a real
or virtually integrated delivery system.
Are of a sufficient size to support comprehensive
performance measurements.
Are capable of internally distributing shared
savings payment.
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FFS
Capitation
ACO
Payment Model
Providers are paid per
service
Providing fixed, "upfront"
payments unrelated to volume of
services changes incentives.
Reduces incentives to increase
volume and can work with
other reforms that promote
coordinated, lower-costs
quality care.
Requires patients to
enroll with specific
providers
No
Yes-Patients must enroll with
designed provider
No-Patients can be assigned
based on previous care
patterns.
Strenghtens primary
care/fosters care
coordination
No- Little incentive to
support primary care
or coordination
Yes
Yes
Fosters accountability
for total per-capita
costs and imporved
quality
Little incentive to
Accountable for per capita cost
manange total percapita costs or improve
quality
Accountablity for costs in the
form of shared savings with
eligiblility for shared savings.
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More doctors are joining
hospitals and health
systems rather than go
into private practice.
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 Triple
aim:
◦ Population health status and
outcomes of care
◦ The care experience
◦ Total cost of care – Delivering
the outcomes
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Tightly aligned physician network

Contracting capability
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Large enough population base
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Willingness to accept common cost
and quality metrics
Sufficient data infrastructure
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1.
People-centered foundation
2.
Health Home
3.
High-Value network
4.
Population health data management
5.
ACO leadership
6.
Payer Partnership
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 Fee-for-service
 Bundled
plus bonus
payments plus bonus
 Global
capitation
 Partial
capitation
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These Principles are:
1.
2.
3.
4.
Stakeholders should identify specific
targets that reduce cost.
Evaluate objectively whether these
targets were met.
They should share success financially.
Should engage in a process of continued
monitoring.
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1.
Quality
2.
Cost effectiveness
3.
Care-coordination
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ACO Impact
Care
Effectiveness/
Population
Health
Safety
ACOs have access to medical, pharmacy, and
Laboratory claims from payers
• Cancer Care Screenings
• Diabetes Care (LDL and H1c tests, eye exams, etc.)
• Coronary Artery Disease Care (LDL test)
• High-risk medication for the elderly
• Appropriate testing for patients using high-risk
medications
Patient
Engagement
Overuse/
Efficiency
• Imaging for low back pain (in absence of “red
flags”) during first 30 days
• Inappropriate antibiotic prescribing
• Utilization rates of select services (e.g., C-section)
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ACO Impact
ACOs use specific clinical data (e.g., electronic
laboratory results) and limited survey data
Safety
• Immunization rates for children and adolescents
• Patients with diabetes whose blood sugar (H1c) is in control
• Patients with diabetes or ischemic vascular disease whose
lipids (LDL) are in control
• Patients with hypertension whose blood pressure is in control
• “Never events” in hospitals
Patient
Engagement
• Physician instructions understood (CAHPS)
• Care received when needed (CAHPS)
Overuse/
Efficiency
• Episode-based resource use – linked to quality
measures for common medical (e.g. diabetes, AMI)
and common surgical conditions (e.g. hip
replacement)
Care
Effectiveness/
Population
Health
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Reduced hospitalizations and other wastes.
Care coordination and care transition for
chronic disease and complex patients.
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Internal process improvement.
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Informed patient choices.
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Prevention and wellness.
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Coordination between PCPs
and specialists.
Support for preventing
complications in specialty
care and reducing costs.
Successful ACOs will
promote more effective
specialists care and PCPspecialists coordination and
higher-value specialty care.
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1.
Quality
2.
Cost effectiveness
3.
Care-coordination
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1.
Quality
2.
Cost effectiveness
3.
Care-coordination
4.
Culture of teamwork
X2
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Best practices for specialty coordination with
medical homes
Best practices for all specialty procedure
registries/patient tracking for improving
care-and supporting meaningful performance
measurements
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Improved professional working environment
Realization that at some point volume and
intensity will not be able to be increased
further
Understanding that the care currently being
delivered is not in the best interest of our
country or patients
Knowledge of continued reform attempts by all
healthcare stakeholders to improve quality and
bend the cost curve
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Steve Wegner
[email protected]
(919)380-9962
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